Permit -, A CITY OF TIGARD
,,,, ��, ,, DEVELOPMENT SERVICES SEWER CONNECTION
h I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639.4171 PERMIT
PERMIT # • SWR98 -0139
DATE ISSUED: 07/01/98
PARCEL: 2S101AD -02600
SITE ADDRESS... :12625 SW 69TH AVE
SUBDIVISION :WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK LOT •031 JURISDICTION: TIG
TENANT NAME :MCCROSKEY CLINIC
USA NO • FIXTURE UNITS...: 89
CLASS OF WORK... :NEW DWELLING UNITS..: 6
TYPE OF USE :COM NO. OF BUILDINGS: 0
INSTALL TYPE •LTPSWR IMPERV SURFACE: 0 sf
Remarks: McCroskey Clinic RE: PLM98 -0172
Owner: FEES
JOHN MCCROSKEY type amount by date recpt
14125 SW FARMINGTON PRMT $ 13800.00 GEO 07/01/98 98- 306977
BEAVERTON OR 97005 INSP $ 45.00 GEO 07/01/98 98- 306977
Phone #:
Contractor:
OWNER
Phone #: $ 13845.00 TOTAL
Reg C. :
REQUIRED INSPECTIONS
This Applicant agrees to comply with all the rules and regulations
of the Unified Sewage Agency. The permit expires 180 days from
the date issued. The total amount paid will be forfeited if the
permit expires. The Agency does not guarantee the accuracy of the
side sewer laterals. If the sewer is not located at the measurement
given, the installer shall prospect 3 feet in all directions from
the distance given. If not so located, the installer shall purchase
a °Tap and Side Sewer° Permit and the Agency will install a lateral.
ATTENTION: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR AIAP
952 -001 -0010 through OAR 952 -0001 -0080. You may obtain copies of AMIIIIIINOF
these rules or direct questions to OINC by calling (503)246 -1987. 4411111Klear
Issued by. ff!' _ Permittee Signatur �I/ ii
+++++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
Call 639 -4175 by 7:00 p.m. for an inspection needed the next business day
+++++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + ++ + + + + + + + ++
C4fYARD Commercial Building Permit Application Recd By
13125 SW HALL BLVD. Tenant Improvement l � r Date Recd
TIGARD, OR 97223 C6, Date to P.E.
�.J��, Date to DST
(503) 639 -4171 � � , Permit* - 12 • , -p ,3c9
Print or Type Related SWR #
Incomplete or illegible applications will not be accepted Called
Name of Development/Project Existing Building p New Building ❑
Job
Address Street Address Suite Building
lalva.5 0 ( Data
Bldg # City /State Zip Existing Use of Building or Property:
To,ppe.0 Q2 ( 1724- 7 ,
Name
Property Proposed Use of Building or Property:
Owner Mailing Address Suite
No. Of Stories:
City /State Zip Phone
Sq. Ft. Of Project
Occupant Name Occupancy Class(es)
Name
Contractor Type(s) of Construction
Prior to permit Mailing Address Suite
issuance. a copy WiII this project have a Fire Suppression System?
of all licenses Yes p No p
are required If City /State Zip Phone
expired in C.O.T. Americans with Disabilities Act (ADA)
database Valuation X 25% = $ Participation
Oregon Const. Cont Board Uc.# Exp. Date Complete Accessibility Form
Project $
Name - Valuation
Architect Plans Required: See Matrix for number of sets to submit
Mailing Address Suite on back
City /State Zip Phone I hereby acknowledge that I have read this application, that the information
given is correct, that I am the owner or authorized agent of the owner, and
that plans submitted are in compliance with Oregon State Laws.
Engineer Name
Signature of Owner /Agent Date
Mailing Address Suite
Contact Person Name Phone
City /State Zip Phone
FOR OFFICE USE ONLY
Indicate type of work: New 0 Addition 0 Demolition 0 Map/TL# I Land Use:
Accessory Structure 0 Foundation Only 0 Alteration 0
Repair 0 Other O Notes:
Description of work:
TIF:
Note: Site Work Permit Application must precede or accompany Building
Permit Application
I: \COMNEWTI.DOC (DST) 5/98
°• � �,
COMMERCIAL PLAN SUBMITTAL
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EXAMINERS (Note a.) _
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NOTES: KEY:
a. Before returning to DST, Plans examiner gets appropriate j =Job B = gUp
number of revised plans from applicant, stamps and o = Office M = MEC
completes, updates and adds actions. f =Fire P = PLM
u A E ELC
:�:2` .
...,.......:.. ....:.:: . }'::. } }:,!:. <.::.::::.::! <.: }n .: Wash. County F =FPS
.. ... ...... ..r.
c. FPS is a new permit category set aside for fire sprinklers and fire alarms.
d. Effective August 15, 1997, Tualatin Valley Fire and Rescue no longer requires a set of
approved plans to be forwarded to their office.
Exception, continue to forward a copy of approved fire sprinkler and fire alarm plans with
calculations.
�:��.�